The origins of the African Health Initiative track back to more than a decade ago when large increases in global health funding reinvigorated international solidarity to reduce the excess disease burden of low and middle income countries. The ambitious efforts that followed exposed the fragility of national health systems. The Doris Duke Charitable Foundation (DDCF), which at the time was making grants to support biomedical and operations research in Africa, saw stronger health systems as a prerequisite for sustainable country-owned efforts to improve population health. This observation led to the African Health Initiative, which was launched by the foundation in 2007.

In 2009, DDCF funded five partnership projects with lifespans of five to seven years to strengthen district health systems in Ghana, Mozambique, Rwanda, Tanzania and Zambia. Each project tackled health systems with approaches that were tailored to the needs of defined geographical areas that comprised no fewer than 250,000 people. The goal was to save lives, as reflected in measurably reduced mortality rates. Now, five years after DDCF's initial decision to invest in strengthening health systems, the need is more widely acknowledged and no less pressing. It is also clear that, while frameworks and approaches can be identified, there are no simple recipes for success. While we must await the projects' end to assess their impact on population mortality, the teams have already learned a great deal as they finalized their intervention plans and began to implement them.

This special journal supplement offers an early look at the design, challenges and progress of each project. As several strategies related to health service quality and the use of information for decision-making spanned across sites, cross-site learning is also shared. The task of adopting a shared evaluation framework and developing similar measures across five very different projects is also recounted. Last, several commentators, drawing on a range of expertise in global health systems, offer their individual perspectives on the ongoing critical necessity of a health systems approach. But why certain approaches are taken and how this work is accomplished will remain crucial to learning in the field. We salute the teams for sharing the process, not only the outcome, of their work!